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Will Be Processed When Submitted Properly Completed. Belo Sign The Apphication fJ� �j <br /> FOR OFFICE USE: r F APPLICATION AUG 23 979 f UJ <br /> " ( or Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT SAN JOAQUIN LOCAL <br /> (COMPLETE IN TRIPLICATE) — WATER QUALITY HEALTH DISTRICT <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District, <br /> Exact Site Address _ 02 1 City/Town sCla .d <br /> Owner's Name <br /> Phone /� CJI? <br /> Address City � �►TJ <br /> Contractor's Name License#�_ Business Phone_&N P;PQ% t <br /> Contractor's Address Emergency Phone -r— <br /> Is <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes�� No r <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRS <br /> REPLACEMENT❑ \n <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia, of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State WorlDone <br /> PUMP REPAIR: JZ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> i <br /> Describe Material and Procedure j <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County { <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." �! <br /> Contractor's hiring or sub signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ-persons subject to workman's compensation laws of California." <br /> I will ca or a Grout Ins ection prior to grouting and a final inspect' n. <br /> _ t <br /> Signed ��` Title: Date: I <br /> (Draw Plot Plan on Reverse Side) <br /> 1 <br /> FOR DEP RTMENT USE ONLY <br /> PHASEI q <br /> Application Accepted By "� " "'t �_ Date <br /> Additional Comments: <br /> t <br /> Phase 11 Grout InspectionP e final In If,ction t <br /> Inspection By Date _ Inspection B Date 0 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received-By July 31 <br /> BILLING REMITTANCE $ ». REMIT <br /> BASE EXPLANATION l DATE DATE REMITTED AMOUNT DUE CHECKED <br /> ,/ f` AMOUNT <br /> FEE .1 '- 'T[�' ✓ i <br /> LESS <br /> PRORATION ' <br /> PLUS. <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received b Date Receipt N . ! <br /> y p o Permit No. Issuance Date Mailed Delivered <br /> - _ ,APPLICANT"RETURN ALL COPIES TO:'' ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601'E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />